Effect of Inlays, Onlays and Endocrown Cavity Design Preparation on Fracture Resistance and

Fracture Mode of Endodontically Treated Teeth: An In Vitro Study

Running Title: Effect Cavity design preparation on ETT

Authors

Cynthia Kassis, DDS, MSc, DEA,1 Pierre Khoury, DDS, DESS,2 Carina Z Mehanna, DDS,

CES,DEA, PhD,1 Nadim Z. Baba, DMD, MSD, FACP4, Fadi Bou Chebel, DDS, MSc,3 Maha

Daou, DDS, CESA ,CESB,DEA, PhD,5 Louis Hardan, DDS, CES,DEA, PhD,3

1
Department of Esthetic and Restorative Dentistry, St- Joseph University, School of
Dentistry, Beirut, Lebanon
2
Department of Prosthodontics, Lebanese University, School of Dentistry, Lebanon
4
Advanced Education Program in Implant Dentistry, Loma Linda University, School of
Dentistry, CA
5
Dental Materials, St- Joseph University, School of Dentistry, Beirut, Lebanon

Corresponding author

Corresponding Dr. Cynthia Kassis, Department of Esthetic and Restorative Dentistry, St-
Joseph University, School of Dentistry, Beirut, Lebanon

Email: Cynthiakassis@usj.edu.lb

Funding: Saint Joseph University FMD137

Conflict of interest statement: The authors deny any conflicts of interest in regards to the
current study.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/jopr.13294.

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Accepted date: November 16, 2020

Abstract

Purpose: To evaluate the fracture resistance and failure modes of endodontically treated

mandibular molars restored with different designs of inlays, onlays and endocrowns.

Materials and Methods: Extracted mandibular third molars (n=180) were used. An access

cavity was prepared on the occlusal surface of each tooth and the roots were obturated with

gutta percha. All specimens were randomly divided into 6 groups (n=30/group) according to

the cavity design and the restoration material used. C: control group without access cavity

preparation. IE: MOD inlay preparation with EverX Posterior (GC Europe) in the pulp

chamber. IG: MOD inlay preparation with G-aenial Universal Flo (GC America) in the pulp

chamber. OE: onlay preparation with EverX Posterior (GC Europe) in the pulp chamber. OG:

onlay preparation with G-aenial Universal Flo (GC America) in the pulp chamber. EC:

endocrown with an empty pulp chamber. All restorations were fabricated with CAD/CAM

system using CERASMART® (GC Dental products Europe, Belgium) CAD/CAM blocks.

Specimens were thermal-cycled and were subjected to a compressive load applied at 30°

angle relative to the long axis of the tooth with a universal testing machine. Results were

statistically analyzed by ANOVA followed by Tukey post hoc tests. Chi-square test and

Fisher Exact tests were used for the comparisons among groups.

Results: The mean fracture strength was significantly different between the groups (P<.001);

it was significantly highest for intact teeth, followed by endocrowns (P=.021). The strength

was significantly lower for inlays (with G-aenial Universal Flo and EverX Posterior),

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intermediate for onlays with EverX Posterior followed by onlays with G-aenial Universal

Flo.

Conclusions: Endocrowns exhibited higher fracture resistance than other tested composite

resin groups. Endocrowns and onlays showed a more favorable failure mode than inlay

restorations.

Keywords: endodontically treated teeth, nanoceramic, inlays, onlays, CAD/CAM,

endocrowns, resistance to fracture, failure mode

Endodontically treated teeth (ETT) present higher risk of fracture compared with vital

teeth, because of their structural differences and loss of tooth structure.1 It is a challenge to

regain the fracture resistance of tooth lost due to cavity preparation.2 The restoration of an

endodontically treated tooth must ensure the biomechanical performance similarly to an

intact tooth. Structural resistance is related to appropriate retention and adhesive integration

between root dentin, core reconstruction and final restoration, forming a unique and

integrated complex.3

Post endodontic tooth fractures might occur because of the loss of the tooth substance

during the endodontic access cavity preparation, root canal instrumentation as well as root

canal filling technique or inadequate post space preparation and selection.3 In fact,

endodontic access cavity preparation was reported as the second largest cause of loss of tooth

structure.4 The quantity and quality of the remaining tooth structure should be considered in

order to define the best restorative option for each case, since extensive restorations weaken

the remaining tooth structure.5 Moreover, tooth weakening is caused by the loss of strategic

internal tooth architecture at the center of the tooth and the marginal ridges.6 A wide range of

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cavity designs for mesio-occlusal-distal (MOD) preparations were proposed for the posterior

teeth dependent on the caries extent and residual tooth intact walls.1,7,8 The depth and design

of cavity preparations are critical factors for fracture resistance. Preparation of an endodontic

access cavity compromises the strength of a tooth, resulting in an increased susceptibility to

fractures.9

According to the cusp coverage, the types of restorations can be classified as inlays,

which are preparations with no covered cusps, onlays, where at least one cusp is covered, or

overlays, where all cusps are covered.2-10 Cuspal coverage results in increasing the longevity

of indirect posterior restorations. Endocrown assemble the intraradicular post, the core, and

the crown in one component leading to a monoblock restoration.11 It uses the pulp chamber to

increase the stability through adhesive cement.12 Minimally invasive cavity preparations for

posterior restorations demonstrate the benefit of conservation of tooth structure and

improvement of stress distribution.13

Computer-aided design, computer-aided manufacture (CAD/CAM) composite resins,

and CAD/CAM hybrid ceramics are among materials available for use in the treatment of

missing tooth structure. Hybrid ceramics are polymer infiltrated ceramic materials that merge

characteristics of ceramic and polymer.16 CERASMART® blocks (GC Dental products

Europe, Belgium) are composite resin nanoceramic blocks that consist of a polymeric matrix

reinforced by ceramic nanohybrid fillers.17 EverX Posterior (GC Europe) is a composite

resin-based material comprised of polyethylene and glass fibers and indicated for the

restoration of endodontically treated teeth. This composite resin increases tooth strength and

mimic the stress absorbing properties of dentine. It is indicated to be used as bulk base in

high stress bearing areas.18

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 The aim of this study was to compare the fracture resistance of different teeth

preparation designs on endodontically treated teeth. The null hypotheses were that the

different teeth preparations will not affect the fracture resistance of endodontically treated

teeth, the filling of the cavity access will not affect the fracture resistance of endodontically

treated teeth, and the different teeth preparations will not affect the localization of tooth

fracture.

Materials and methods

This study was approved by the ethical committee of Saint-Joseph University (USJ-

2017-54). One hundred and eighty extracted mandibular molars free of cracks and caries with

similar bucco-lingual and mesio-distal dimensions were selected for this study. The teeth

were cleaned and stored in 0.2% thymol solution (Merck KGaA, Darmstadt, Germany). Each

molar was embedded in a self-polymerizing resin (Nic Tone®, MDC Dental,

Jalisco, Mexico), perpendicularly, 2 mm below the cemento-enamel junction and parallel to

the long axis of the tooth. Following root canal treatment, the access cavity of each tooth was

cleaned using ethylene alcohol to remove residual sealer and debris from the walls. All access

cavities had approximatively the same sizes.

The specimens were randomly divided into 6 groups of 30 specimens each. Group C

is the control group without access cavity preparation. Group IE is the MOD inlay

preparation with EverX Posterior (GC Europe) in the pulp chamber. Group IG is the MOD

inlay preparation with G-aenial Universal Flo (GC America) in the pulp chamber. Group OE

is the onlay preparation with EverX Posterior (GC Europe) in the pulp chamber. Group OG is

the onlay preparation with G-aenial Universal Flo (GC America) in the pulp chamber and

Group EC is the endocrown with an empty pulp chamber. (Table 1) Access cavities of groups

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IE, IG, OE and OG were etched with 37% phosphoric acid (GC Etching Gel; GC Europe) and

the bonding agent (G-premio BOND; GC Europe), was applied and light-cured for 20

seconds (Satelec Mini Led curing light, A-dec Inc). The access cavities of group IE and OE

were filled with fiber reinforced composite (Ever X Posterior, GC Dental) and IG and OG

with G-aenial Universal Flo (GC Dental) and light-cured for 40 seconds. Resin materials

formed a flat restoration wall at the roof of the pulpal chamber. A single operator (CK)

prepared a standardized mesio-occlusal-distal (MOD) cavity preparation on all teeth using a

high-speed tapered diamond bur (6 ˚taper) (Intensiv, Switzerland) with copious irrigation.

The prepared cavity occupied one-third of the bucco-lingual distance in order to guarantee a

minimum of 2 mm of buccal and lingual remaining wall thickness, and a horizontal pulpal

wall of 3 mm in depth. Proximal boxes were prepared to create an isthmus with 2 mm depth

and divergent buccal and lingual axial walls. The gingival margin was located 1 mm above

the cemento-enamel junction.

For the onlay preparation, the functional and non-functional cusps were reduced by 2

mm with 90˚ butt-joint margins (Fig 1). All restorations were fabricated with CAD/CAM

system using resin nanoceramic CAD/CAM blocks (Cerasmart, GC Corp). Preparations were

digitized using a Wieland scanner (IvoclarVivadent, Germany). The design of the restorations

was established with similar anatomy and contour with the use of the Exocad software and

saved as Standard Tessellation Language (STL) file. The blocks were milled accordingly

using CERASMART® Flexible Nano Ceramic CAD/CAM blocks (Cerasmart, GC Corp),

with the use of a 5-axis milling machine (Cerec Inlab MCX5, Sirona, Germany) following

the manufacturer’s instructions.

Once all the restorations were milled, the intaglio surface of each restoration was

treated with hydrofluoric acid (9% porcelain etch, Ultradent), rinsed with water and air dried

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for then coated with a silane agent (G Multi- PRIMER; GC Europe) following

manufacturer’s recommendations.

All teeth surfaces were etched with 37% phosphoric acid (GC Etching Gel, GC

Europe) for 15 seconds, rinsed with water and gently air dried for 10 seconds. A bonding

agent (G-premio BOND; GC Europe) was applied and polymerized for 20 seconds. All

restorations were cemented with a dual-cure resin composite cement (G-CEM LinkAce, GC

Europe) according to the manufacturer’s instructions. All specimens were then stored in

distilled water at 37°C for 24 hours before fracture testing. All teeth were thermal cycled

(Thermocycler THE-1200, SD Mechatronik, Germany) in distilled water for 5,000 cycles at 5

ºC and 55 ºC, with 50 seconds’ dwell time and 10 seconds’ transfer time. The fracture

resistance of each specimen was tested with the use of a Universal Testing Machine (YLE

GmbH, Walstrabe, 64732 Bad Konig, Germany). To apply the load on the teeth, a 5 mm

diameter stainless-steel ball was oriented on the center of the occlusal surface at a 30° angle

relative to the long axis of the tooth at a constant loading rate of 1.0 mm/min. Failure was

defined as the load at maximal load as reported by the Instron universal testing machine, and

force at failure was recorded in Newtons (N) for each specimen. The fracture pattern of each

specimen was subjectively evaluated with the use of two classifications. The first

classification describes the localization of the fracture (Table 2) and the second one on the

prognosis of the tooth (restorable versus non-restorable).

Statistical software (SPSS statistics, v25, IBM) was used. The level of significance

was set at -p value< 0.05. Kolmogorov-Smirnov tests were used to assess the normality

distribution of continuous variables. Analysis of variance followed by Tukey post hoc tests

(HSD) were performed to compare the fracture strength between groups. Chi-square tests and

Fisher Exact tests were used to compare the type of fracture among groups.

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Results

The Fracture loads and fracture modes are presented in Table 3. The mean fracture

strength (FS) was significantly different between the groups (p<0.001). FS was significantly

the highest for intact teeth, followed by endocrowns (P=.021). The strength was significantly

lower for Inlays (with G-aenial Universal Flo and EverX Posterior), intermediate for onlays

with EverX Posterior followed by onlays with G-aenial Universal Flo. The difference was not

significant between inlays with EverX Posterior and inlays with Gaenial (P=1.000). However,

the mean force was lower with onlays with EverX Posterior compared to onlays with G-

aenial Universal Flo (P=.032).

The restorability of the teeth depends significantly on the type of restoration (P<.001)

(Table 4). Only 36.7% of intact teeth were restorable. Fifty six point seven percent of inlays

with EverX Posterior and 60.0% of inlays with G-aenial Universal Flo were restorable. The

vast majority of teeth restored with CERASMART onlays with EverX Posterior (93.3%) and

G-aenial Universal Flo (93.3%) and 93% of CERASMART endocrowns were restorable.

The level of fracture depended significantly on the type of restoration (P=.001) (Table

5). Fracture type 3 occurred in the vast majority of overlays with EverX Posterior (76.7%),

G-aenial Universal Flo (80.0%) and endocrowns (83.3%) (P=.971). However, the fracture in

inlays (in the presence of EverX Posterior or G-aenial Universal Flo, in the pulp chamber)

was recorded as: type 2 (10.0%), type 3 (EverX Posterior: 30.0%; G-aenial Universal Flo:

40.0%), type 4 (Inlay with EverX Posterior: 20.0%; Inlay with G-aenial Universal Flo:

10.0%) (P=.705), and type 5 (40.0%). Fracture Resistance varied significantly according to

the preparation design.

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Discussion

Treatment of Endodontically treated teeth (ETT) remains a great challenge.19 In fact,

tooth fracture’s etiologies are multiple and uncontrollable by dentists.20 The search for an

ideal adequate tooth preparation and the ideal material to prevent fracture after ETT in order

to decrease the impact on the tooth resistance strength have been constant.21-22 Indirect

restorative techniques demonstrated an improved fracture resistance in endodontically treated

posterior teeth compared with direct techniques.23 Materials used to restore ETT must satisfy

a balance between preserving tooth structure and maximizing the strength of the restoration.11

For these reasons, 3 different preparation designs have been selected in this study: inlay,

onlay and endocrown. Concerning the choice of CAD/CAM nanoceramics resin,

CERASMART showed a significant higher mean fracture resistance load value compared to

other materials.16-17 The results of this study showed that the highest fracture resistance was

with intact teeth, which is confirmed by many studies that showed that ETT had a

significantly lower resistance to fracture.24

Moreover, there was a significant difference between teeth preparation designs. The

highest fracture resistance was obtained with endocrowns. The strength was significantly

lower for inlays and intermediate with onlays. Fracture resistance varied with different tooth

design preparations, thus rejecting the null hypotheses. Moreover, fracture localizations and

modes have changed with different preparation design cavities. These results are in

agreement with previous studies where the highest fracture resistance was recorded with

endocrowns.16,25

Fracture resistance of teeth with inlay cavity preparations depends on the remaining

wall thickness limits that should be more than 2 mm.1,26 Moreover, complete occlusal

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coverage exhibited the most favorable pattern of stress distribution in the tooth-restoration

complex and large preparations require cuspal coverage to prevent possible fracture.27,28 In a

3D finite element analysis study, Yoon et al.29 reported that the onlay cavity design protected

the tooth structure more effectively than the inlay design for adhesively bonded leucite-

reinforced ceramic restorations. Other studies have shown that endocrowns are indicated in

endodontically treated teeth and that they had a better fracture strength outcome when

compared to conventional restorations.11,25 However, Gré et al.30 reported similar value of

fracture resistance with endocrowns and conventional crowns.

Recently, new types of composite resin materials have been introduced to replace the

dentin and to absorb stress to minimize the risk of fracture. It has been reported that materials

with low modulus of elasticity tend to absorb stress, concentrating it inside the material and

not transferring it to the tooth structure.31 Özkır found that fiber reinforcement improved the

fracture resistance of composite resin.32 In another study, Goracci et al.33 showed that the

highest fracture toughness and flexural strength was recorded with EverX Posterior compared

to other bulk fill and conventional resin composites when their thickness was over 4 mm.

However, the results of this study showed that the fracture resistance of onlays with chamber

cavities restored with G-aenial Universal Flo was higher than that obtained when chamber

cavities were restored with EverX Posterior. These results rejected the third null hypotheses

because the choice of the restorative material in the pulp chamber influenced the fracture

resistance. This is also confirmed by a study that emphasizes the necessity of retentive slots

with EverX Posterior to prevent cuspal fracture.34 Furthermore, the results are in agreement

with a study which found that short fiber-reinforced resin composite material (SFRC) did not

ameliorate the fracture strength compared to conventional composites.35

Recent studies have reported that the use of SFRC under onlay restorations is not

useful to increase the load resistance capacity. The thickness of this material will affect the

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physical properties and the durability.36 The high thickness of the CAD/CAM restorations

and the loading stress generated during the fracture could have contributed to limit the

behavior of the FRCs substructure.37 Similar to our results, Keçeci et al.24 showed that intact

teeth had a high percentage of “non-restorable” fractures. However, untreatable fractures

were detected at a significantly high level with ceramic MOD inlays.38,39 This difference

would be explained by the presence in this study of a composite resin filling in the cavity

chamber that could have deviated the fracture and ameliorated the prognosis.40 According to

the localization of fracture lines, inlay restorations showed mixed type of failure. Consistent

with these results, it was demonstrated that cusps coverage helped to distribute stress and to

localize fracture lines.1

This in vitro study has some limitations in terms of simulating clinical conditions. In

fact, clinical fracture results from fatigue caused by cyclic loading in multiple directions. In

this study, specimens were subjected to a thermal cycling aging protocol and compressive

and axial loads only. Furthermore, adhesive resin cement is indicated for hybrid ceramics

including CERASMART®. But we have used G-CEM LinkAce which is self-adhesive resin

cement. It could be considered as a limitation by affecting the integrity of tooth-restoration

complex. For that reason, we have pretreated the enamel before luting to improve the bond

strength of self-adhesive resin cements.41

Conclusion

There were significant differences between the value of fracture resistance of the groups

with different restoration. Endocrowns and onlays showed a more favorable failure mode

than inlay restorations and fracture modes varied with the different restorations’ designs.

With inlay design, the difference was not significant between EverX Posterior and Gaenial.

However, the mean force was lower with onlays with EverX Posterior compared to onlays

with G-aenial Universal Flo.

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Figure Captions

Figure 1: Teeth preparations A. Conventional inlay preparation B. Onlay and endocrown

preparations were prepared by reducing the inlay preparation 2 mm occlusally.

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Material Composition Manufacturer
G-aenial Universal Flo

Flowable, light-cured, Resin (UDMA, bis-MEPP and TEGDMA) 31%wt; GC Corp., Tokyo,
radiopaque resin fillers (silicon dioxide [16nm], strontium glass Japan
composite [200nm]) 69 wt% and traces of photoinitiator
EverX posterior

(Fiber-reinforced Bis-GMA, TEGDMA, glass fiber, barium glass, GC Corp., Tokyo,

composite) silicone dioxide, PMMA (poly methylmetacrylate), Japan
photoinitiators
CERASMART Composite resin material (BisMEPP, UDMA,
DMA) with 71 wt% silica and barium glass
nanoparticles
Ceramic type: hybrid GC dental products Europe, Belgium
nanoceramic
G-CEM linkAce

Self-adhesive resin UDMA, dimethacrylate, surface treated silica, GC Corp., Tokyo,

luting cement silane, synergist Japan

Table 1. Materials used in this study

Bis-GMA: bisphenol A diglycidil methacrylate

UDMA: urethanedimethacrylate
TEGDMA: triethyleneglycolimethacrylate
BisMEPP: 2,2-bis (4 methyacryloxypolyethoxyphenyl) propane
DMA: dodecyl dimethacrylate

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Table 2. Classification of fracture patterns

Types of Fracture Fracture Patterns

Type 1 No visible fracture

Type 2 Fracture restricted to the tooth

Type 3 Fracture restricted to the restoration

Type 4 Fracture of the restoration and the tooth above CEJ

Type 5 Fracture of the restoration and the tooth below CEJ

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Table 3: Fracture strength in different groups

n Mean Std Minimum Maximum

(N) Deviation (N) (N)
(N)
Intact teeth 30 1498.90 d 358.390 830 2200
Endocrown CERASMART 30 1300.53 c 298.167 875 2047
Onlay CERASMART with 30 1065.03 b 233.119 763 1566
G-aenial Universal Flo
Onlay CERASMART with 30 930.70 a ,b 188.207 707 1400
EverX
Inlay Cerasmart with 30 772.10 a 132.388 530 1040
G-aenial Universal Flo
Inlay Cerasmart with Ever X 30 766.90 a 155.806 516 1187

a Significant difference when compared with Onlay, Endocrown and Intact teeth groups
b Significant difference when compared with Inlay, Endocrown and intact teeth groups
C Significant difference when compared with Inlay, Onlay and Intact teeth groups
d Significant difference when compared with Inlay and Onlay groups and Endocrown

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Table 4: Percentage of recoverable teeth
Recoverable tooth Non-recoverable tooth
Endocrown CERASMART 28(93.3%) 2(6.7%)
Onlay CERASMART with G-aenial 28(93.3%) 2(6.7%)
Universal Flo
Onlay CERASMART with EverX 28(93.3%) 2(6.7%)
Inlay CERASMART with G-aenial 18(60.0%) 12(40.0%)
Universal Flo
Inlay CERASMART with EverX 17(56.7%) 13(43.3%)
Inlay CERASMART with EverX 17(56.7%) 13(43.3%)
Teeth 11(36.7%) 19(63.3%)

Table 5. Localization of fractures

fracture pattern
2 3 4 5
Intact Teeth 30(100.0%) 0(0.0%) 0(0.0%) 0(0.0%)
Inlay with EverX 3(10.0 %) 9(30.0 %) 6(20.0 %) 12(40.0 %)
Inlay with G-aenial 3(10.0 %) 12(40.0 %) 3(10.0 %) 12(40.0 %)
Universal Flo
Overlay with EverX 0(0.0 %) 23(76.7 %) 5(16.7 %) 2(6.7 %)
Overlay with G- 0(0.0 %) 24(80.0 %) 5(16.7 %) 1(3.3 %)
aenial Universal Flo
Endocrown 0(0.0 %) 25(83.3 %) 4(13.3 %) 1(3.3 %)

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